Health Insurance 101

Key Terms To Help You Understand Your Health Insurance Coverage

Having problems understanding your insurance policy and coverage? You are not alone! Following are several key insurance terms which will help you crack the insurance code!

Adjustments to fee-for-service charges
The difference between the fee-for-service charges based on the practice's fee schedule and the amount expected to be paid by patients for third-party payers. This represents the value of services performed for which payment is not expected due to contractual agreements or other reasons.
The amount your plan will pay a physician, group or hospital, as stated in your policy, toward the cost of the service or procedure to be performed by the physician.
The summary of your medical bill. It is generated after insurance has paid the original claim. The insured may be responsible for charges appearing on the bill/invoice/statement.
Certificate of insurance
The printed description of the benefits and coverage provisions forming the contract between the carrier and the customer. Discloses what it covered, what is not, and dollar limits.
The form that the physician files with a health insurance company that details the services and procedures performed by the physician, on your behalf, and other pertinent data that is required by the health insurance company to receive payment.
Federal legislation that lets you, if you work for an insured employer group of 20 or more employees, continue to purchase health insurance for up to 18 months if you lose your job or your coverage is otherwise terminated. For more information, visit the Department of Labor.
Co-payment or "co-pay"
The part of your medical bill you must pay each time you visit the doctor. This is a pre-set fee determined by your health insurance policy.
The part of your bill, in addition to a co-pay, that you must pay. Co-insurance is usually a percentage of the total medical bill - for example, 20 percent.
The amount you must pay for medical treatment before your health insurance company starts to pay-for example, $500 per individual or $1,500 per family. In most cases, a new deductible must be satisfied each calendar year.
Denial of claim
Refusal by an insurance company to honor a request by an individual (or his or her provider) to pay for health care services obtained from a health care professional.
Spouse and/or unmarried children (whether natural, adopted or step) of an insured. Insurance varies as to what age a child ceases to be a dependent. This age needs to be verified with your insurance policy.
Effective date
The date your insurance coverage begins. You are not covered before the effective date of the policy.
Situation, instance, condition, injury or treatment that the health plan states will not be covered and for which the health plan will not pay any benefits.
Explanation of benefits (EOB)
The insurance company's written explanation to a claim, showing what they paid and what the client must pay. Sometimes accompanied by a benefits check.
The physician has contracted a payment schedule with the health insurance company to provide you with medical care. The physician will submit your medical bill directly to the health insurance company for payment. However, you may be responsible for a co-payment, deductible and/or co-insurance according to your health insurance company.
Maximum dollar limit
The maximum amount of money that an insurance company (or self-insured company) will pay for claims within a specific time period. Maximum dollar limits very greatly. They may be based on or specified in terms of types of illnesses or types of services. Sometimes they are specified in terms of lifetime, sometimes for a year.
Non-covered charges
Costs for medical treatment that your health insurance company does not pay. You may wish to determine if your treatment is covered by your health insurance policy before you are billed for these charges by the doctor's office.
The physician is not contracted with the health insurance company to provide you with medical treatment. You are responsible for the payment of the medical care. The physician may agree to submit your medical bill directly to the payer for payment. However, you may be responsible for an increased co-payment, deductible, co-insurance and/or additional charges according to your insurance company benefit plan.
Out-of-pocket maximum
A predetermined limited amount of money that an individual must pay out of their own savings, before an insurance company or (self-insured employer) will pay 100 percent for an individual's health care expenses.
Pre-existing conditions
A medical condition that is excluded from coverage by an insurance company, because the condition was believed to exist prior to the individual obtaining a policy from the particular insurance company.  These are prohibited under the ACA (Acountable Care Act).
Primary care provider (PCP)
A health care professional (usually a physician) who is responsible for monitoring an individual's overall health care needs. Typically, a PCP serves as a "quarterback" for an individual's medical care, referring the individual to more specialized physicians for specialist care.
Primary health insurance company
The health insurance company that is responsible to pay your benefits first when you have more than one health insurance plan.
Provider is a term used for health professionals who provide health care services. Sometimes, the term refers only to physicians. Often, however, the term also refers to other health care professionals such as hospitals, nurse practitioners, chiropractors, physician therapists, and others offering specialized health care services.
Secondary health insurance company
The secondary health insurance company is not the first payer of your claims. The remaining claim balance will be sent to a secondary health insurance company, if provided, after payment is received by the primary health insurance company. In most cases, your primary insurance is the policyholder whose birth date is first within the year.
If you still have questions regarding your insurance coverage, it is best to contact your employer's Human Resources or Benefits Personnel.
If you have questions about a statement or bill you have received from this office, please contact our Billing Department at (513) 248-3063.